Selected Podcast
Non-Surgical Treatment for Bunions
Dr. Ravick discusses non-surgical treatment for bunions.
Featuring:
Arnold Ravick, MD
Dr. Arnold S. Ravick was raised in Silver Spring, Maryland. He has been in private practice of Podiatric Medicine and Surgery in the D.C. area for more than 25 years. He specializes in Sports Medicine of Foot and Ankle with an area of interest in custom foot othotics. Dr. Ravick treats patients of all ages, athletes from beginner to professional and classically trained ballet dancers. He is active in the D.C. Podiatric Medical Association having served as president for two terms. Dr. Ravick is a published author and often quoted in local and social media. He enjoys sports, politics and spending time with his family. Transcription:
Melanie Cole: Welcome to The GW HealthCast. I'm Melanie Cole. Today's topic is nonsurgical treatment options for Bunyan's. Joining me as Dr. Arnold Ravick, he's an assistant clinical professor of surgery with The George Washington University Hospital and The GW Medical Faculty Associates and is affiliated with The George Washington University Hospital. Dr. Ravick, it's a pleasure to have you join us. Let's start for the listeners. What is a Bunion?
Dr. Ravick: A bunion is a deformity or growth of bone behind the big toe generally where you get an enlargement of bone there and often the big toe slants toward the second toe. There's also something called a tailor's bunion, which is a growth of bone near the little toe. Analogous to the one we just spoke of.
Host: So what are the most common reasons for them to form? And if your parents have them, will you get them? Is there a genetic component to this?
Dr. Ravick: So the reason people get bunions is the way they walk. It's the way their foot functions. Generally, it's the rolling around of the foot, putting more stress on the joints. We talked about the one by the big toe, which is the most common type is because your foot rolls in calling pronation or flattening of your foot. The hereditary component comes in and there is one is you inherit the kind of foot you have or foot type from your folks and from your family. So if a lot of people in your family have bunion's, there is a possibility increased that you'll get bunion's yourself. It's not from shoes, which is what everybody believes. Shoes don't cause bunions but shoes can exacerbate or make them worse. In other words, if you have a bunion or your toe is getting more deformed or crooked and you get in a narrower shoe or a tighter shoe or shoe that doesn't fit you well, it can make it worse.
Host: Well thank you for that answer and clearing that up cause that was going to be one of my next questions. So if a shoe is not to blame, but our pro nation is, then what are some complications that can cause if left unattended or if they get worse if we don't address that pronation?
Dr. Ravick: So a lot of the causes that bring people to see a podiatrist that come into our office are the big toe pushes over so far that it starts to make other toes deformed. Hammertoes, they buckle, they can get corns, calluses, corrosive, harder skin around those joints or even on the bottom of the foot. Because often not only does the bone go sideways, but it goes up or elevate. So pressure is born more in the middle of the foot, can cause ingrown toenails because the pressure between the toes increases. So it pushes the nail into the skin at the corner causing an ingrown toenail. You can get compression of nerves that run between the toes and get something called a neuroma, which is a scar tissue growth around a nerve from the tightness of the bone on the nerve itself.
Host: So then when do they need attention and what's the first thing you do for patients whose bunions are starting to cause pain? Tell us about some of these nonsurgical treatments you would try. First line of defense.
Dr. Ravick: Well, the first thing I do is I have her discussion with a person who comes in and I try to ask them, or I try to explain there are other things we can do and what are they looking for? If a person says, I can't stand the way this looks, you know, I want this big knot of bone to come off my foot, and then that's a surgical patient. But I think the majority of people are looking for one, pain relief, which there are a lot of options. We use topical medication which can help. There are injectable medications that can help. Oral medication. There are a lot of options. But aligned with what you were asking. I think the main thing is to try and keep that joint more flexible. By definition, a joint that doesn't work well, which is what a bunion is, becomes arthritic at some point. So it gets tighter and that makes shoes harder to wear walking more painful. And that's a lot of what brings people to seek treatment. So if you can keep it more limber through stretching exercises, which we do a lot of, we do a lot of flexibility exercises and stretching. Also there are devices you can wear between your toes. It'll help keep them more flexible. I have patients use yoga toes a lot, which are rubber devices. They fit between your toes that you use, not when you're wearing shoes to try and keep them more flexible. It's like an exercise mechanism that I think helps the joint.
Host: So when you say flexibility, and obviously like you said, this is a non-moving joint, but what are you talking about for listeners? You're talking about literally taking the big toe and pushing it out, stretching it and moving it around. You mentioned, you know, the yoga device and things they can use, but if they're just taking their hands and manually stretching it out, is that how they would do it is just kind of move the toe around?
Dr. Ravick: Well, moving the toe around can be helpful. But generally what I have in do our stretching exercises where they're up on their toes, up on the heels, you want to stretch out their Achilles, you want to stretch out the plantar fascia, which is the arch itself in the middle of the foot. A lot of these things connect because often their leg and or their foot will be tight. As to the joint itself, we use the separating devices people use, we have yoga toes or something that stretch it both sideways and up and down. And they're helpful in keeping the joint from being as stiff. So we use that a lot. But also you have to realize in a lot of people it's changing the kind of shoe they wear. Now as I go over with people, many times they don't have to be ugly shoes, but they have to have one, not as much pressure on the joint itself. So a lot of times that's a wider toe box, which is where the front of the toes are. Two, it's a softer material, which is what's becoming very popular in athletic shoes and dress shoes. They're much more made out of fabric that are softer material, not as much of a hard leather so it doesn't bind or push the joint as dramatically or let it be as stiff.
Host: What about orthotics taking some of the pressure, if you are a pronator, if your arch is falling, if you know any of those kinds of things. Do you use devices like that and do they help?
Dr. Ravick: Yes, we use them a lot and they do help. So they're a big category of things. When you talk about orthotics. In my way of thinking, orthotics are only the custom made devices. Everything else is a support or an arch support. Orthotics are the custom made devices that change the way you walk. So it does stop the pronation. It does change the way your foot hits the ground, which is the most important part of walking. It does change the way the toes will grip and buckle, things like that. Over the counter supports do you have a place, they don't change the way you walk, they are more allowing you to walk in a certain way and then trying to deflect pressure. Usually what I do with the over the counter devices, I will, they adapted somehow I can put increased padding on it. I can tilt it. There are things I can do with the device, but I find most of the off the shelf devices really don't change the pressure. So they don't give patients as much pain relief as one accustomed device or one that we can modify some.
Host: So what other modalities might you try? Does soaking, we've talked about exercise and flexibility and orthotics, custom made and ones that you can purchase at the store or your local running store. What other modalities can you try, which would then be some of the final things you would try before surgery becomes the discussion?
Dr. Ravick: So I generally prefer heat rather than ice. I think that ice is used for acute injuries, which volumes generally are not unless you hit it or break the bone or break some of the other bones involved in that joint. Then obviously ice, elevation, rest, compression would be appropriate. Like any other acute injury, like a sprained ankle. But for chronic things heat makes more sense. So I advise heat, I try to counsel people obviously not to burn themselves, use heat more slowly. It also helps with the stretching. So I have people heat their foot before they'll stretch before they use yoga toes, before they do the other stretching exercises that it makes us more elastic and more pliable. Other treatments that we'll use, we use cortisone injections. We use physical therapy treatment on the joint. There are a fair amount of topicals now. There are prescriptive topicals that are versions of anti-inflammatories that we use and there are a lot of, obviously over the counter anti-inflammatories or topical medications now with CBD and other things in them that the jury is not out on. But people do use a fair amount.
Host: So what is your best advice? Is there any way to prevent bunions and what would you like the listeners to know about treatment options available?
Dr. Ravick: Prevention is early detection. Like almost anything in medicine. If we get a patient who's younger, a lot of times they do run in families or I do a lot of sports medicine so I see a lot of younger athletes and when you see them and they're starting to form one, if we can get them in orthotics early enough and change the way they walk, they won't get bunions. I've had patients for 30 years that their bunions never gotten any worse. If you can maintain it with proper alignment. They have to realize they have to use the orthotics a lot of the time. And sometimes obviously in sandals and certain kinds of shoes. It's difficult to use orthotics, not impossible but difficult. You can use them in dress your shoes, you can use them in heals. You can use them in athletic shoes almost exclusively they're for athletic shoes. But there are address types are a lot of different types of orthotics. So it's controlling the foot function, it's keeping the joint flexible and it's making good shoe choices again. And again, it doesn't mean you have to give up the shoes that you want to wear to work or they're comfortable. I mean nowadays, I think most people in our city, I live, I'm in the Washington DC area and practice in DC. People I think keep their dress shoes or their work shoes in their purse and their backpack and put them on later. I was just commenting, I think the shoe shine guy on the street where I practice, might go out of business. Everybody seems to wear athletic shoes nowadays, which is much better for me and them and easier to put orthotics in.
Host: What great advice and what a really interesting topic so many people suffer from these, and don't know what to do. Thank you for all that great advice, Dr. Ravick. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Ravick or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. This is Melanie Cole.
Melanie Cole: Welcome to The GW HealthCast. I'm Melanie Cole. Today's topic is nonsurgical treatment options for Bunyan's. Joining me as Dr. Arnold Ravick, he's an assistant clinical professor of surgery with The George Washington University Hospital and The GW Medical Faculty Associates and is affiliated with The George Washington University Hospital. Dr. Ravick, it's a pleasure to have you join us. Let's start for the listeners. What is a Bunion?
Dr. Ravick: A bunion is a deformity or growth of bone behind the big toe generally where you get an enlargement of bone there and often the big toe slants toward the second toe. There's also something called a tailor's bunion, which is a growth of bone near the little toe. Analogous to the one we just spoke of.
Host: So what are the most common reasons for them to form? And if your parents have them, will you get them? Is there a genetic component to this?
Dr. Ravick: So the reason people get bunions is the way they walk. It's the way their foot functions. Generally, it's the rolling around of the foot, putting more stress on the joints. We talked about the one by the big toe, which is the most common type is because your foot rolls in calling pronation or flattening of your foot. The hereditary component comes in and there is one is you inherit the kind of foot you have or foot type from your folks and from your family. So if a lot of people in your family have bunion's, there is a possibility increased that you'll get bunion's yourself. It's not from shoes, which is what everybody believes. Shoes don't cause bunions but shoes can exacerbate or make them worse. In other words, if you have a bunion or your toe is getting more deformed or crooked and you get in a narrower shoe or a tighter shoe or shoe that doesn't fit you well, it can make it worse.
Host: Well thank you for that answer and clearing that up cause that was going to be one of my next questions. So if a shoe is not to blame, but our pro nation is, then what are some complications that can cause if left unattended or if they get worse if we don't address that pronation?
Dr. Ravick: So a lot of the causes that bring people to see a podiatrist that come into our office are the big toe pushes over so far that it starts to make other toes deformed. Hammertoes, they buckle, they can get corns, calluses, corrosive, harder skin around those joints or even on the bottom of the foot. Because often not only does the bone go sideways, but it goes up or elevate. So pressure is born more in the middle of the foot, can cause ingrown toenails because the pressure between the toes increases. So it pushes the nail into the skin at the corner causing an ingrown toenail. You can get compression of nerves that run between the toes and get something called a neuroma, which is a scar tissue growth around a nerve from the tightness of the bone on the nerve itself.
Host: So then when do they need attention and what's the first thing you do for patients whose bunions are starting to cause pain? Tell us about some of these nonsurgical treatments you would try. First line of defense.
Dr. Ravick: Well, the first thing I do is I have her discussion with a person who comes in and I try to ask them, or I try to explain there are other things we can do and what are they looking for? If a person says, I can't stand the way this looks, you know, I want this big knot of bone to come off my foot, and then that's a surgical patient. But I think the majority of people are looking for one, pain relief, which there are a lot of options. We use topical medication which can help. There are injectable medications that can help. Oral medication. There are a lot of options. But aligned with what you were asking. I think the main thing is to try and keep that joint more flexible. By definition, a joint that doesn't work well, which is what a bunion is, becomes arthritic at some point. So it gets tighter and that makes shoes harder to wear walking more painful. And that's a lot of what brings people to seek treatment. So if you can keep it more limber through stretching exercises, which we do a lot of, we do a lot of flexibility exercises and stretching. Also there are devices you can wear between your toes. It'll help keep them more flexible. I have patients use yoga toes a lot, which are rubber devices. They fit between your toes that you use, not when you're wearing shoes to try and keep them more flexible. It's like an exercise mechanism that I think helps the joint.
Host: So when you say flexibility, and obviously like you said, this is a non-moving joint, but what are you talking about for listeners? You're talking about literally taking the big toe and pushing it out, stretching it and moving it around. You mentioned, you know, the yoga device and things they can use, but if they're just taking their hands and manually stretching it out, is that how they would do it is just kind of move the toe around?
Dr. Ravick: Well, moving the toe around can be helpful. But generally what I have in do our stretching exercises where they're up on their toes, up on the heels, you want to stretch out their Achilles, you want to stretch out the plantar fascia, which is the arch itself in the middle of the foot. A lot of these things connect because often their leg and or their foot will be tight. As to the joint itself, we use the separating devices people use, we have yoga toes or something that stretch it both sideways and up and down. And they're helpful in keeping the joint from being as stiff. So we use that a lot. But also you have to realize in a lot of people it's changing the kind of shoe they wear. Now as I go over with people, many times they don't have to be ugly shoes, but they have to have one, not as much pressure on the joint itself. So a lot of times that's a wider toe box, which is where the front of the toes are. Two, it's a softer material, which is what's becoming very popular in athletic shoes and dress shoes. They're much more made out of fabric that are softer material, not as much of a hard leather so it doesn't bind or push the joint as dramatically or let it be as stiff.
Host: What about orthotics taking some of the pressure, if you are a pronator, if your arch is falling, if you know any of those kinds of things. Do you use devices like that and do they help?
Dr. Ravick: Yes, we use them a lot and they do help. So they're a big category of things. When you talk about orthotics. In my way of thinking, orthotics are only the custom made devices. Everything else is a support or an arch support. Orthotics are the custom made devices that change the way you walk. So it does stop the pronation. It does change the way your foot hits the ground, which is the most important part of walking. It does change the way the toes will grip and buckle, things like that. Over the counter supports do you have a place, they don't change the way you walk, they are more allowing you to walk in a certain way and then trying to deflect pressure. Usually what I do with the over the counter devices, I will, they adapted somehow I can put increased padding on it. I can tilt it. There are things I can do with the device, but I find most of the off the shelf devices really don't change the pressure. So they don't give patients as much pain relief as one accustomed device or one that we can modify some.
Host: So what other modalities might you try? Does soaking, we've talked about exercise and flexibility and orthotics, custom made and ones that you can purchase at the store or your local running store. What other modalities can you try, which would then be some of the final things you would try before surgery becomes the discussion?
Dr. Ravick: So I generally prefer heat rather than ice. I think that ice is used for acute injuries, which volumes generally are not unless you hit it or break the bone or break some of the other bones involved in that joint. Then obviously ice, elevation, rest, compression would be appropriate. Like any other acute injury, like a sprained ankle. But for chronic things heat makes more sense. So I advise heat, I try to counsel people obviously not to burn themselves, use heat more slowly. It also helps with the stretching. So I have people heat their foot before they'll stretch before they use yoga toes, before they do the other stretching exercises that it makes us more elastic and more pliable. Other treatments that we'll use, we use cortisone injections. We use physical therapy treatment on the joint. There are a fair amount of topicals now. There are prescriptive topicals that are versions of anti-inflammatories that we use and there are a lot of, obviously over the counter anti-inflammatories or topical medications now with CBD and other things in them that the jury is not out on. But people do use a fair amount.
Host: So what is your best advice? Is there any way to prevent bunions and what would you like the listeners to know about treatment options available?
Dr. Ravick: Prevention is early detection. Like almost anything in medicine. If we get a patient who's younger, a lot of times they do run in families or I do a lot of sports medicine so I see a lot of younger athletes and when you see them and they're starting to form one, if we can get them in orthotics early enough and change the way they walk, they won't get bunions. I've had patients for 30 years that their bunions never gotten any worse. If you can maintain it with proper alignment. They have to realize they have to use the orthotics a lot of the time. And sometimes obviously in sandals and certain kinds of shoes. It's difficult to use orthotics, not impossible but difficult. You can use them in dress your shoes, you can use them in heals. You can use them in athletic shoes almost exclusively they're for athletic shoes. But there are address types are a lot of different types of orthotics. So it's controlling the foot function, it's keeping the joint flexible and it's making good shoe choices again. And again, it doesn't mean you have to give up the shoes that you want to wear to work or they're comfortable. I mean nowadays, I think most people in our city, I live, I'm in the Washington DC area and practice in DC. People I think keep their dress shoes or their work shoes in their purse and their backpack and put them on later. I was just commenting, I think the shoe shine guy on the street where I practice, might go out of business. Everybody seems to wear athletic shoes nowadays, which is much better for me and them and easier to put orthotics in.
Host: What great advice and what a really interesting topic so many people suffer from these, and don't know what to do. Thank you for all that great advice, Dr. Ravick. You're listening to the GW Healthcast. Please visit GWDocs.com to get connected with Dr. Ravick or another provider, or call 1-888-4GW-DOCS to schedule an in-person or virtual appointment. This is Melanie Cole.